Peripheral Artery Disease Lower Extremity
Overview
Overview
Top 10 Take-Home Messages
- Peripheral artery disease (PAD) is a common cardiovascular disease associated with increased risk of amputation, myocardial infarction, stroke, and death, as well as impaired quality of life, walking performance, and functional status.
- This guideline defines 4 clinical subsets of PAD: asymptomatic PAD (may have functional impairment), chronic symptomatic PAD (including claudication), chronic limb-threatening ischemia, and acute limb ischemia.
- Detection of PAD in most patients is accomplished through the history, physical examination, and the resting ankle-brachial index.
- Health disparities in PAD are associated with poor limb and cardiovascular outcomes and must be addressed at the individual patient and population levels, with interventions coordinated between multiple stakeholders across the cardiovascular community and public health infrastructure.
- Effective medical therapies for patients with PAD should be prescribed to prevent major adverse cardiovascular events and major adverse limb events for patients with PAD, including antiplatelet (generally single antiplatelet) and antithrombotic therapy, lipid-lowering (ie, high-intensity statin) and antihypertensive therapy, management of diabetes, and smoking cessation. Rivaroxaban (2.5 mg twice daily) combined with low-dose aspirin (81 mg daily) is effective to prevent major adverse cardiovascular events and major adverse limb events in patients with PAD who are not at increased risk of bleeding.
- Structured exercise is a core component of care for patients with PAD. It includes supervised exercise therapy and community-based (including structured home-based) programs.
- Revascularization (endovascular, surgical, or hybrid) should be used to prevent limb loss in those with chronic limb-threatening ischemia and can be used to improve quality of life and functional status in patients with claudication not responsive to medical therapy and structured exercise.
- Care for patients with PAD, and especially those with chronic limb-threatening ischemia, is optimized when delivered by a multispecialty care team.
- Foot care is crucial for patients with PAD across all clinical subsets and ranges from preventive care and patient education to advanced care in the setting of chronic limb-threatening ischemia. Podiatrists and other specialists with expertise in foot care, wound-healing therapies, and foot surgery are important members of the multispecialty care team.
- The PAD National Action Plan outlines 6 strategic goals to improve awareness, detection, and treatment of PAD nationwide. Implementation of this action plan is recognized as a top advocacy priority by the writing committee.
In the print version of this pocket guide, colors in tables and figures correspond to Class of Recommendations and Level of Evidence tables on pages 54–55.
Table 2. Definitions of PAD Key Terms
| Term | Definition |
|---|---|
| ALI | Acute (≤2 wk) hypoperfusion of the limb that may be characterized by: pain, pallor, pulselessness, poikilothermia, paresthesias, and/or paralysis. ALI is further classified according to the Rutherford classification system (Table 4). |
| Anatomic level | Anatomic subsets to localize disease in the lower extremity. Patients with PAD can have multilevel arterial disease across multiple segments.
|
| Angiosome-based blood flow | Uninterrupted arterial flow to the anatomic territory of a source artery in the skin and deep tissues. In the context of PAD, the angiosome refers to the skin region and underlying tissue, generally with a wound, supplied by a specific infrapopliteal artery. |
| Claudication | Fatigue, cramping, aching, pain, or other discomfort of vascular origin in the muscles of the lower extremities that is consistently induced by walking and consistently relieved by rest (usually within approximately 10 min). Claudication that limits functional status is known as functionally limiting claudication. Claudication is recognized as a manifestation of chronic symptomatic PAD (see Section 2.1, “Recognizing Clinical Subsets for PAD”). |
| CLTI | A condition characterized by chronic (>2 wk) ischemic rest pain, nonhealing wounds and ulcers, or gangrene attributable to objectively proven arterial occlusive disease. Current nomenclature has evolved from the previous commonly used term of CLI to reflect the chronic nature of this condition and its potentially limb-threatening nature with associated risk for amputation and to distinguish it from ALI. |
| Endovascular revascularization | Catheter-based revascularization procedures employing modalities such as percutaneous transluminal (balloon) angioplasty, drug-coated balloon angioplasty, stenting (bare metal, drug coated, or covered), and atherectomy. |
| Functional status | Patient’s ability to meet basic needs, fulfill usual roles, and maintain health and well-being (activities of daily living). Walking ability/ performance and mobility are components of functional status. |
| Hybrid revascularization | Approach to revascularization that includes endovascular and surgical components either concomitantly or in a staged manner. |
| In-line (pulsatile) blood flow | Uninterrupted arterial flow via named infrapopliteal arteries to the foot. |
| Inflow versus outflow | Inflow refers to arteries proximal to the superficial femoral artery (aortoiliac, common femoral arteries). Outflow refers to arteries distal to the superficial femoral artery (popliteal and infrapopliteal arteries). |
| MACE | Variably defined but usually includes death (all-cause or cardiovascular), MI, acute coronary syndrome (acute MI, unstable angina), and stroke. May also include heart failure, rehospitalization for cardiovascular causes, and other cardiovascular endpoints. |
| MALE | Variably defined but usually includes major amputation and endovascular or surgical lower extremity revascularization (initial or reintervention). May also include ALI. |
| Multispecialty care team for PAD |
|
| Regions of the foot |
|
| Structured exercise program | An exercise program planned by a qualified health care professional that provides recommendations for exercise training with a goal of improving functional status over time. The program provides individualized recommendations for frequency, intensity, time, and type of exercise. |
| Structured community-based exercise program | A structured exercise program that takes place in the personal setting of the patient (eg, home, surrounding neighborhood, fitness facility). The program is self-directed with as-needed guidance of health care professionals who prescribe a structured exercise regimen similar to that performed in a supervised program setting. Community-based programs may incorporate behavioral change techniques, delivered by in-person or virtual health coaching or the use of activity monitors. Table 14 provides more detail regarding this form of structured exercise. |
| Supervised exercise therapy | A supervised, structured exercise program that takes place in a hospital or outpatient facility that is directly supervised by a physician or advanced practice provider and most often implemented by a clinical exercise physiologist or nurse. Table 14 includes more detail regarding this form of structured exercise. |
| Surgical revascularization | Surgical procedures that may involve endarterectomy to remove plaque, thrombectomy, or bypass surgery to reconstruct arterial blood flow. |
| Thrombolysis | Administration of thrombolytic agents, generally through a catheter placed directly within an area of thrombus in an artery. |
| Tissue loss |
|
| WIfI |
|
Diagnosis
Diagnosi...
...ing Clinical Subsets of PAD
...re 1. Clinical Subsets of P...
...l Subsets of Patients With PADHaving trouble vie...
...y and Physical Examination to Assess for PAD...
...patients at increased risk of PAD (Tab...
...at increased risk of PAD (Table 5), a compreh...
...able 5. Patients at Increased Risk fo...
Table 6. History and Physical Examination...
...native Diagnosis for Leg Pain or Claud...
...gure 2. Algorithm for Diagnostic Test...
...ABI and Additional Physiological Testi...
...esting AB...
...with history or physical examination findin...
The resting ABI should be reporte...
...ts at increased risk of PAD (Table 5), s...
...s not at increased risk of PAD (Table 5) and...
...e ABI and Additional Physiological Testing...
...n patients with suspected PAD, toe pre...
...with suspected chronic symptomatic PAD (ie, exert...
...In patients with PAD and an abnormal res...
...nts with chronic symptomatic PAD, it is reason...
...atients with suspected CLTI, it is r...
...nts with CLTI with nonhealing wounds or gangren...
...ternative Diagnoses for Nonhealing Lower Extremity...
3.2. Imaging for P...
...with functionally limiting claudica...
...ts with CLTI, duplex ultrasound, CTA, MRA, or ca...
...ts with suspected PAD (ie, potenti...
...ents with a confirmed diagnosis of PAD in wh...
...al Considerations in PAD: Risk Amplifier...
...ifiers of Cardiovascular and Limb-Related Ri...
...evaluation of patients with PAD, clinic...
...ated Risk AmplifiersHaving trouble viewing...
...ealth Disparities and PAD-Related Risk Amp...
...lth Disparities in PAD...
...icians and health care systems should activ...
...tions in Management of PAD in Older P...
In older patients (ie, ≥75 years of age) wi...
...10. Geriatric Syndromes and Conside...
Treatment
...atment...
...rapy and Preventive Footcare for Pati...
...re 4. Medical Therapy and Foot Care...
...iplatelet and Antithrombotic Therapy for PAD...
...ts with symptomatic PAD, single antipla...
...patients with symptomatic PAD, single an...
...ients with symptomatic PAD, single antipl...
...patients with symptomatic PAD, low-dose...
...er endovascular or surgical revasculariza...
...After endovascular or surgical revascularizati...
...r endovascular revascularization for PAD, dual ant...
...ter endovascular or surgical revascularizatio...
...ents with asymptomatic PAD single anti...
...ith symptomatic PAD without recent revascularizat...
...In patients with symptomatic PAD, t...
...l revascularization for PAD with a pros...
...atients with PAD without another indica...
...-Lowering Therapy for PAD...
...ients with PAD, treatment with high-in...
...ith PAD who are on maximally tolerated sta...
...In patients with PAD who are on maxim...
...le 11. High-, Moderate-, and Low-Inten...
...Antihypertensive Therapy for PAD...
...tients with PAD and hypertension, an...
...s with PAD and hypertension, a systolic blood pr...
...In patients with PAD and hypertension, the...
...oking Cessation for PAD...
Patients with PAD who smoke cigarettes o...
Patients with PAD who smoke cigaret...
...ith PAD should be advised to avoid exp...
...iabetes Management for P...
...patients with PAD and type 2 diabetes, use of glu...
...ith PAD, management of diabetes should be co...
...In patients with PAD and diabetes, gl...
...ical Therapies for Cardiovascular R...
...nts with PAD should receive an ann...
...ents with PAD should receive the sever...
...patients at high cardiovascular risk, a diet em...
...atients with PAD, B-complex vitamin suppl...
...ents with PAD, chelation therapy (eg, EDTA) is no...
...ients with PAD, vitamin D supplementation i...
...ns for Leg Symptoms in Chronic Symptomati...
...ilostazol...
...In patients with claudication, cilostaz...
...ts with PAD, cilostazol may be usef...
...In patients with PAD and congestive heart...
...ntoxifylline
...patients with chronic symptomatic PAD...
...ation Therapy...
...ith chronic symptomatic PAD, chelation...
...Preventive Foot Care for PAD
...s with PAD, providing general prev...
...s with PAD, foot inspection by a clinician at...
...ts with PAD at high risk for ulcers and...
...In patients with PAD, a comprehensive...
...with PAD, referral to a foot care specialist, whe...
...Factors for Development of Foot Ulce...
...ponents of a Comprehensive Foot Evalu...
...ercise Therapy for PAD...
...n patients with chronic symptomatic PAD,...
...with chronic symptomatic PAD, a structured commu...
...In patients who have undergone revascularizatio...
...ents with functionally limiting claudication, SE...
...tients with chronic symptomatic PAD,...
In patients with chronic symptomatic PAD, th...
In patients with chronic symptomatic...
Table 14. Structured Exercise Program...
....1. Revascularization for Asymptomati...
...ients with asymptomatic PAD, it is reason...
...tients with asymptomatic PAD, revascular...
.... Algorithm for Revascularization for Claudi...
...cularization for Claudication...
...on for Claudication: Initial Decision-Ma...
...In patients with functionally limitin...
...nts with functionally limiting claudicatio...
...patients with claudication who have had an adequat...
...scularization for Claudication: Aortoiliac Di...
...atients with functionally limiting...
...ents with functionally limiting claudicat...
...scularization for Claudication: Common Femoral...
...with functionally limiting claudic...
...s with functionally limiting claudication and hemo...
...on for Claudication: Infrapopliteal Disease...
...nts with functionally limiting claudication...
...ients with functionally limiting claudication...
...r Surgical Revascularization for F...
...tients who are undergoing surgical...
...Components of Care for CLTI...
...re 7. Algorithm for Management of CL...
...1. Team-Based Care for CLT...
...ents with CLTI, a multispecialty care team sho...
...specialty Care Team for PADHaving trouble...
...16. Factors That May Influence Revasculariza...
...evascularization for C...
...rization Goals for CLTI...
...with CLTI, surgical, endovascular,...
...n patients with CLTI, an evaluation for...
...ascularization Strategy fo...
...ients undergoing surgical revascularization f...
...ith CLTI due to infrainguinal disease, anatomy, av...
...n patients with CLTI who are candida...
...In patients with CLTI for whom a surgical app...
...patients with CLTI and nonhealing wou...
...nts with CLTI with ischemic rest pain...
...nimizing Tissue Loss for C...
....1. Pressure Offloading for CLTI...
...Patients with CLTI and diabetic foot ulc...
...h PAD and previous diabetic foot ulcers sho...
...tients with CLTI and foot ulcers who do not have d...
...Wound Care and Management of Infection for CLTI...
...patients with CLTI, prompt management of foot in...
In patients with CLTI with nonhealing wo...
...nts with CLTI with nonhealing diabetic foo...
...Components of Wound Care for Patients With CL...
...proach to the “No Option” Patient With CLTI...
...n patients with CLTI for whom revascu...
...patients with CLTI for whom revascu...
...with CLTI for whom arterial revascularization...
...atomic Classification of the "No Option" Pati...
...Amputation for CLTI...
...with CLTI who require amputation, evaluat...
...ith CLTI, primary amputation is indi...
...with CLTI, a patient-centered app...
...s with CLTI undergoing minor amputat...
...with CLTI, retrospective assessmen...
...Factors Influencing QOL Among Amputees...
...ent Factor...
...Walking with prosthesis Above knee (vers...
...sional-Controlled Fac...
...g of amputation Informed decision ma...
...Acute Limb Ischemia...
...Algorithm for Diagnosis and Management of A...
...linical Evaluation and Diagnostic...
...ALI should be evaluated on an emergency basi...
In patients with suspected ALI, the initial cli...
...patients with ALI who have a complicated history...
11.2. Management of A...
...1. Revascularization for...
...with ALI and a salvageable limb, revasculariza...
...tients with ALI and a salvageable limb who are...
...patients presenting with ALI from chemotherapeuti...
...ients with ALI with a nonsalvageable limb, r...
...ve Therapies to Minimize Tissue Loss...
...Patients with ALI should be monitored and...
...In patients with ALI with a threatene...
...nts with ALI and prolonged ischemia in whom revas...
...Anticoagulation for ALI...
...patients with ALI, regardless of cause or anatomi...
...Evaluation for the Cause of ALI...
...ith ALI, a comprehensive medical history...
...nts with ALI, testing for a cardiovascular c...
...erlying Causes of ALIHaving trouble viewing tabl...
...itudinal Follow-Up of PAD...
...al Principles...
...tients with PAD, with or without revasculariz...
...s with PAD, coordination of care among cli...
...nal Status and QOL...
...ents with PAD, with or without revascular...
...cal Therapy...
...ients with PAD, long-term use of G...
...strevascularization Follow-...
...ients with PAD who have undergone lower extre...
...atients with PAD who have undergone lower ex...
...patients with PAD who have undergone infra...
...tients with PAD who have undergone endova...
...patients with PAD who have undergone infraingui...
...ehealth...
...atients with PAD, telehealth can be an alternat...